Therapist Form

7/23/2019 Therapist Form

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Bio-Medical Instruments Inc.2387 East Eight Mile Road

Warren, MI 480!-248"

#hone$ %8"-7%"-%070 &a'$ %8"-7%"-8!

Public Listing Information

Title ( Re)uired &ields

First Name

Middle

Last

Company Name

Address

Adress 2

City

State

Zip

Business Phone

Fax

Email

Contact Methods Phone Email Fax

e!site

Practicin" Since

A#era"e cost per session $

Accept %nsurance& 'es No

%ntroduction Para"raph(



Private Information (if different from public listing)

Title

First Name

Middle

Last

Address

Adress 2

City

State

Zip

Business Phone

Fax

Email

MA)* ALL T+AT APPL' %T+ AN ,(

Academic LicensingBachelor o- Science in Education Certi.ed Clini

Bachelor o- Science in Nursin" Clinical Psych0octor o- Chiropractics Clinical Social

0octor o- 0ental Sur"ery Family and C

0octor o- Education Licensed Clini

0octor o- Medicine Licensed Clini

0octor o- 1ptometry Licensed ra

0octor o- 1steopathy Licensed %nde

0octor o- Philosophy Licensed Marr

0octor o- Psycholo"y 3Ph04 Licensed Marr

0octor o- Psycholo"y 3Psy04 Licensed Marr

0octor o- Science Licensed Men0octor o- Social or/ Licensed Men

Master o- Arts Licensed Pro-

Master o- Counselin" Licensed Psyc

Master o- Education Licensed Psyc

Master o- Science Licensed Sch

Master o- Science in Nursin" Licensed Soci

Master o- Science in Social or/ Marria"e and

Master o- Social Science Marria"e5 Fa



Master o- Social or/ Psycholo"ical

Phd Candidate )e"istered %n

)e"istered Nurse Social or/er

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Certication AAP

Academy o- Clinical Social or/ers Ame

Ad#anced Clinical Practitioner BC%

American Association -or Marria"e and Family Therapy BC%

American Association o- Pro-essional +ypnotherapists Clini

American Board o- Examiners in Clinical Social or/ Edu

American Board o- Family Psycholo"y %n +

American Board o- Medical Psychotherapy %SN

American Board o- Psycholo"ical +ypnosis )es

BC%A Certi.ed in Bio-eed!ac/

BC%A Certi.ed in Neuro-eed!ac/

BC%A6Certi.ed in Pel#ic Muscle 0ys-unction Bio-eed!ac/

Board Certi.ed 0iplomate in Clinical Social or/

Board Certi.ed in Child and Adolescent Psycholo"y

Board Certi.ed in Clinical Social or/

Certi.ed Alcohol and 0ru" Counselor

Certi.ed Clinical Mental +ealth Counselor

Certi.ed Family Nurse Practitioner

Certi.ed %ndependent Social or/er

Certi.ed Marria"e and Family Therapist

Clinical Specialist in Adult Psychiatric and Mental +ealth Nursin"

0iplomate5 American Academy o- Beha#ioral Medicine

0iplomate5 American Board o- Psychiatry and Neurolo"y

0iplomate5 %nternational Academy o- Beha#ioral Medicine5 Counselin" and Psycholo"y

0iplomate5 Neuropsychiatry

National Academy o- Mental +ealth Counselors

National Board o- Certi.ed Counselors

National Certi.ed Counselor

National )e"ister o- +ealth Ser#ices Pro#iders in Psycholo"y

7EE Technician

7EE60iplomate

)e"istered +ealth Care Pro#ider

ModalitiesEC

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Er"onomics

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Temperature

Specialties %rrita!le Bo9e

Addiction *nee Pain

An"er Mana"ement Lo9er Bac/ P

Anxiety Mood 0isorde

Arthritis Myo-ascial Pai

Asper"ers Neuromuscul

Asthma Pain Mana"eAttention 0e.cit 0isorder:+yperacti#ity 0isorder Par/inson;s a

Autistic Spectrum 0isorders Pea/ Per-orm

Breathin" Pro!lems Phantom Lim

Chest pain Post Traumati

Chronic 0isease Mana"ement Posture )elat

Chronic Pain 7EE Assess

Closed +ead %n=ury )aynaud;s Sy

Conduct and Attachment 0isorders )eha!

Constipation Sleep 0isorde

0epression Smo/in" Ces0e#elopmental 0isorders Spinal Cord %n

0yspha"ia Stress Mana"

Epilepsy and Sei>ure Stress Mana"

Fecal %ncontinence Stump Pain

Fi!romyal"ia Su!stance A!

eriatric Temporoman

+eadaches Tinnitus

+ypertension Traumatic Bra

+yper#entilation ?rinary %ncon

%nterstitial Cystitis

Acceptance

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ia"e and Family Counselor

ia"e and Family Therapist

ia"e5 Family and Child Counselor

al +ealth Counseloral +ealth Ser#ices

ssional Counselor

holo"ical Associate

holo"ical Examiner

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Family Counselor

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Associate

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Mem!er

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Certi.ed

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Equipment UsedAlpha Stim

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Therapist Form

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